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Incident Reports

Incident reporting, assessment and mitigation are a vital element of creating and enhancing the safety of GWO training. To promote good practices and learning GWO publishes its incident reports once investigations are complete. These are published anonymously to encourage collective learning and the sharing of experiences and mitigating actions across the training community. For the GWO Secretariat incident reporting directly feeds into the review and maintenance of GWO standards contributing to the development of safer training.

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Case number:
4871316779
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Significant incident
-
incident date
July 25, 2023
-
training setting
-
Fixed
Summary
-
A course participant sustained a upper arm bone fracture during the an evacuation practice.
Mitigation action
-
Training slides updated to share this case with future course participants, i.e. the proper way to grasp ropes, how to position oneself before descending, and how to eliminate nervousness before descending.
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Case number:
4835067936
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Module
-
BST First Aid
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
July 19, 2023
-
training setting
-
Fixed
Summary
-
A course participant felt dizzy and unwell when looking at slides explaining catastrophic external bleeding.
Mitigation action
-
Medical self-assessment form improved to include a new condition of sensitivity to bleeding injuries. Instructors will also inform participants of slide content before showing graphic pictures.
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Case number:
4666149186
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Module
-
ART Hub Rescue
Version
-
N/A
Incident Significance
Incident
-
incident date
June 19, 2023
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training setting
-
Fixed
Summary
-
Instructor was hit by a hatch and broke two fingertips.
Mitigation action
-
Updated operating instructions and a mechanism installed to secure the hatches.
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Case number:
6245560990
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Module
-
ART Hub, Spinner & Inside Blade Rescue Refresher
Version
-
N/A
Incident Significance
Incident
-
incident date
June 15, 2023
-
training setting
-
Fixed
Summary
-
A course participant bent down during course and strained their back.
Mitigation action
-
The course participant was to helped and the course was paused. No further actions needed.
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Case number:
4595755881
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
June 6, 2023
-
training setting
-
Fixed
Summary
-
A course participant rubbed the middle finger of their right hand on the screw in the outer side of a ladder when descending with an injured person on the ladder.
Mitigation action
-
When practicing on (infrastructure) ladders, instructors are to ensure that all participants have gloves on before starting the exercise.
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Case number:
4471568004
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Module
-
BR Blade Repair
Version
-
N/A
Incident Significance
Incident
-
incident date
May 15, 2023
-
training setting
-
Fixed
Summary
-
An instructor and course participant carried a safety glass shield to the vacuum infusion table using glass-carrying suction cups. While attempting to position the shield on the table, it slightly scraped the ground and shattered into pieces. Both suffered minor cuts.
Mitigation action
-
Glass shields no longer to be used and replaced with aluminium shields.
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Case number:
4410243368
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Module
-
ART Nacelle, Tower & Basement Rescue
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
May 3, 2023
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training setting
-
Fixed
Summary
-
During the raising of the manakin, the R550 rope attached to the manikin, became caught in the pelican hook, and tore apart the rope. After lowering it, the instructor noticed that the rope had gotten wedged in a small gap between the gate and hook side of the pelican hook, resulting in the tear.
Mitigation action
-
Moving forward the rigging has to be confirmed by competent individuals before a lift or movement takes place.
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Case number:
4332350009
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
April 19, 2023
-
training setting
-
Fixed
Summary
-
Course participant complained of pain in their ankle at completion of training. During a “side of the ladder” rescue exercise, the casualty´s body pressed against the participant´s legs, pressing their ankle into the ladder.
Mitigation action
-
Re-iterate importance of all participants being comfortable in saying “stop” at any point during practical training. Also, instructors will encourage participants to consider the placement of rescue devices for ladder rescues, incl. position of rescuer and orientation of casualty.
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Case number:
4333908295
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Module
-
BST Fire Awareness
Version
-
N/A
Incident Significance
Significant near-miss
-
incident date
April 19, 2023
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training setting
-
Fixed
Summary
-
Training provider had bought new gloves for fire exercises, which were believed to be leather gloves, all over. However, during an exercise, a course participant felt the heat on their hand. On inspection, the outer layer of the new gloves turned out to have some plastic areas.
Mitigation action
-
New gloves ordered.
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Case number:
4185965339
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Module
-
BST Sea Survival
Version
-
N/A
Incident Significance
Incident
-
incident date
March 22, 2023
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training setting
-
Fixed
Summary
-
During an exercise in a life raft, a participant got one foot stuck under another participant and twisted the knee, causing swelling and pain.
Mitigation action
-
Sea Survival instructors trained more intensively on the topic of stress among participants.
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Case number:
4049398793
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Module
-
BST Fire Awareness
Version
-
N/A
Incident Significance
Incident
-
incident date
February 27, 2023
-
training setting
-
Fixed
Summary
-
While participating in an evacuation from a smoke-filled room, a course participant cut their wrist on the corner of a cabinet. The participant was blind folded, on hands and knees sweeping floor with hands when the wrist came in contact with a sharp corner, resulting in a cut.
Mitigation action
-
The sharp corner covered and protected from further contact. Ensure that course participants wear all PPE, including gloves.
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Case number:
4000736374
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Module
-
ART Hub Rescue
Version
-
N/A
Incident Significance
Incident
-
incident date
February 16, 2023
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training setting
-
Fixed
Summary
-
While setting up a fall arrest lanyard and positioning lanyard, a course participant went to step up on ladder structure when his left knee struck the side railing of the structure. The participant felt the need to rush during the rescue activity which lead to hitting the railing.
Mitigation action
-
Going forward, focus will be put into slowing down and making a clear plan.
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Case number:
3434471411
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Module
-
BST Working at Heights
Version
-
N/A
Incident Significance
Incident
-
incident date
October 22, 2022
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training setting
-
Fixed
Summary
-
A course participant climbing down from a ladder, stepped on a manikin that was lying on the floor and sprained an ankle.
Mitigation action
-
Ensure unobstructed access to and from ladder. Remind participants to keep their composure until the end of the training, and that every step of the ladder must be stepped until the ground is reached.
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Case number:
3389720296
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Module
-
BST Fire Awareness
Version
-
N/A
Incident Significance
Incident
-
incident date
October 18, 2022
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training setting
-
Fixed
Summary
-
While simulating chaotic conditions during fire evacuation with participants assembling harness with Y-lanyards and Lad-Saf while donning blackout goggles and helmet, a participant felt a metal object (presumably the Lad-Saf or pelican hook) brush against their mouth, resulting in a chipped tooth.
Mitigation action
-
Scenario to be conducted with participants donning only the harness (no additional PFPE).
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Case number:
3273101315
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Module
-
BST Fire Awareness
Version
-
N/A
Incident Significance
Incident
-
incident date
September 15, 2022
-
training setting
-
Fixed
Summary
-
During a FAW exercise with a fake fire in an electrical cabinet, two course participants felt an electric shock using a training CO2 fire extinguisher in a training Nacelle. Severity level low.
Mitigation action
-
A grounded multiplug has replaced the other multiplug in the cabinet, and has been moved away from any direct contact with the CO2.
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